Author: Joseph Coppiano, BS
Co Author #1: Brittany Hickey, MD
Co Author #2: Marvin Sineath, MD
Editor: Idris Amin, MD
Senior Editor: Kristine Karlson MD
41 year old female presents with chronic pain in her bilateral shoulders, elbows, and lumbar spine.
Patient presents complaining of diffuse myalgias and joint pain for many years. She also notes difficulty gripping onto the steering wheel of her car when driving, and occasionally dropping objects throughout the day. She additionally complains of dry mouth, history of oral ulcers, dry eyes, blurry vision, anxiety, and unintentional weight loss. Ibuprofen has offered minimal relief. She reports a sad affect, anxiety, loss of interest in activities, fatigue, poor sleep, and difficulty concentrating on tasks. Denies any recent rashes, sunlight sensitivity, trauma, or suicidal ideation.
Patient was in no acute distress. Eye examination revealed no erythema or discharge. No oral ulcers were appreciated but the patient was missing multiple teeth. No scars, erythema, deformity, or wasting was seen on inspection of the bilateral extremities and lumbar spine. Diffuse tenderness without guarding or rebound was appreciated on palpation of the bilateral extremities and lumbar spine. She displayed bilateral full range of motion and 5/5 strength with resisted shoulder abduction, elbow flexion, grip strength, patellar extension, dorsiflexion, and plantar flexion. Hawkins sign was negative. Sensation was intact bilaterally.
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